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Page 1 of 7 <br /> Secon ry Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FF. <br /> : Gas 4 Less Date of Testing: March 22,2006 <br /> ss: 3434 the Street Stockton,CA WO# 118033 Time:8:00 am <br /> t: Gilbert Silva Phone: (209)944-4577 <br /> ency Was Notified of Testing: March 16,2006 <br /> l Agency Inspector(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hill Corp 1100 North J Street Tulare, CA 93274 <br /> Technician Conducting Test: John Ellis <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,C-61/D40 HAZ License Number: 304147 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Environ Piping and Testing 12/07 <br /> Total Containment Piping and Testing 9/07 <br /> Incon Testing 11/07 <br /> Cadwell Testing <br /> 3. SUMMARY OF TEST RESULTS <br /> Com onent Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> FS1it Tank Annular S ace X Premuim Secondary 3X <br /> mium Fill Sump X Regular Secondary 4 X <br /> remium Pining Sump X <br /> Regular Fill Sump X <br /> Regular Piping Sump X <br /> Premium Secondary 1 X <br /> Regular Secondary 2 X <br /> UDC 12 X <br /> UDC34 X <br /> UDC 56 X <br /> �UDC 78 X <br /> UDC910 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water returned to the storage tank on test trailer. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance-with legal requirements <br /> Technician's Signatur Date: ���? T� �G <br />